Mass Hysteria at Kim Jong Il's Death - Normal Vs Abnormal Grief

No, not the Boxing Day sales. I'm talking about the mass grieving of the people of North Korea, for their recently deceased, supposedly exalted leader, Kim Jong Il. I noted some performances that may contend for the 2012 Oscars.

To them, he was a generous and inspiring leader. Apparently.

The rest of the world may remember him as a brutal dictator, obsessed with the development of nuclear weapons. Either that, or the butt of a mildly-racist, but superbly-funny joke in Team America.

"I'm so Ron-rey!" - Kim Jong Il

I'm surprised that North Korea has been so open about his demise. Their more typical coverage of such an event would have been reports that he had "entered a long-term sleeping contest, and is so far doing remarkably well."The histrionic commotion made me think about the different ways that grief can manifest itself in our intricate, unfathomable, unpredictable human minds. Different ways, not just between individuals, but between cultures as well.

In psychiatry, we make a distinction between "normal" grief and "abnormal" grief. The latter condition has other aliases such as "pathological grief" or "morbid grief". Should psychiatrists meddle in such a natural human reaction?

I have read the prose of numerous anti-psychiatry bloggers and commentators, always opinionated, often absurd, on this website and other internet forums. Their colourful statements and conspiracy theories entertain me. No doubt, they would answer the above question thusly:

"Psychiatrists are funded by drug companies to invent illnesses to sell pills", or:

"Psychiatrists want to make a normal people looked crazy, so they can lock them up, to keep themselves in business", or: "There is no such thing as mental illness," or: "Aliens impregnated my cat." Okay, so maybe not so much the last one ...

I personally feel that there is a role for healthcare professionals when it comes to grief. The primary role, often undertaken by GPs, is to offer support, and promulgate its availability to those who may wish to use it. Some people, after all, do not have the luxury of loved ones with whom to share the burden.

"Grief can take care of itself, but to gain the full value of joy, you must have someone to divide it with." - Mark Twain.

Thanks, Mark, but that kind of invalidates the point I'm trying to make.

The secondary, and often vital role, is the vigilance to detect exceptional cases where people's grief crosses the dark line from normality to mental illness. These cases need to be treated before something tragic occurs.

Several years ago, one of my patient's grief at losing his daughter was so profound that he stopped eating and sleeping. In fact, he stopped doing anything and became almost catatonic. He was found in his flat emaciated and starved, hours away from death. Only after several months of treatment for psychotic depression on a psychiatric ward, did his quality of life improve, until he was eventually discharged home. Of course, this was an extremely unusual case. However, I can't help wonder if his prognosis and outcome would have significantly improved with earlier psychiatric intervention.

"I measure every grief I meet with narrow, probing eyes - I wonder if it weighs like mine - or has an easier size." - Emily Dickinson, American poet.

Normal grief consists of a range of typical symptoms, such as: sadness, denial, emotional numbness, shock, anger and guilt. Often these symptoms are worse for complex or ambivalent relationships between the griever and deceased. Frequently bursting into tears and poor sleep and appetite are also recognised features. However, additionally there are some other, more unexpected symptoms, such as weight loss, hearing the voice or seeing simple images of the deceased, or even obsessional thoughts about the method of death. This state of grief usually lasts up to a year (though the average is half his time). Grief that is more persistent should be monitored closely, lest it slip into the murky world of a deep depression.

Abnormal grief is not just a more intense or prolonged version of the above, but can also entailed more sinister symptoms, like a morbid preoccupation with death or thoughts of suicide. Excessive guilt or a total apathy are also indicators. Sufferers can refuse to interact with others, and sometimes even refuse to leave the house. They can become reclusive or even catatonic, like my ex-patient. Complex or systematic hallucinations, or belief that the deceased still live, are other worrying symptoms, as is a newfound uncharacteristic pugnacity, that leads to the breakdown of relationships.

However, the one most significant element of abnormal grief that trumps all the others is the breakdown of day-to-day functioning.

Regular support and high-intensity bereavement counselling from an experienced specialist can help. Medication can be given if, and only if, co-morbid depressive or anxiety disorders coexist. In short, treatment is available.

Whereas I agree in principle that normal grief should not be medicalised, I also believe that pathological suffering should not be normalised, and swept under the carpet.